Fillable ATM/Debit Card Transaction Dispute Form

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ATM/Debit Card Transaction Dispute Form

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The ATM/Debit Card Transaction Dispute Form form is 2 pages long and contains:

  • 1 signature
  • 20 check-boxes
  • 66 other fields

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1 | ATM/Debit Dispute
Rev. 08/16
ATM/Debit Card Transaction Dispute Form
Name:
ATM/DEBIT Card Number:
Account Number:
Phone Number:
Police Report Number (Please attach a copy if applicable)
At the time of fraudulent transaction, my card was: ATM Card Debit Card
In my possession Lost Stolen Never Received
Date card discovered loss/stolen _______________________
Name(s) of anyone who may have access to card and/or PIN:
ATM DISPUTE
Date of ATM Error: _________________________ Amount of Error: __________________________________
Time of Transaction: ________________________ ATM Location: ____________________________________
Incorrect amount or cash not dispensed. The amount on receipt is $ _____________ : however, $ _____________
was dispensed from the ATM. (Please provide copy of receipt or location of ATM and time of withdrawal took place)
Duplicate posting. The original transaction posted to account for $ __________________ on ___________
Duplicate transaction posted to account for $ __________________ on ____________
I did not authorize an ATM withdrawal for $ ______________ that posted to my account on ___________
ATM card was lost/stolen and an unauthorized withdrawal posted to my account for $___________on ___________
**Please sign bottom of page 2**
DEBIT CARD DISPUTE
Please list disputed transaction(s) below:
Transaction Date(s)
Merchant Name(s)
Transaction Amount(s)
**If more space is needed, please attach a separate sheet of paper** **Complete dispute reason(s) on pg. 2**
2 | ATM/Debit Dispute
Rev. 08/16
Check appropriate dispute reason(s): (check only those that apply)
I did not have knowledge of the above transaction(s) nor did I allow anyone to use my debit card.
(Contact merchant directly for reimbursement prior to disputing charges)
Date merchant contacted: ___________ Merchant response: __________________________________
I authorized the merchant to bill my account on a monthly or continuing basis; however, I canceled or revoked that
authorization.
Date merchant notified: ____________ Cancellation date: __________ Cancellation confirmation number: __________
Duplicate posting. The original transaction posted to account for $ __________________ on ___________
Duplicate transaction posted to account for $ __________________ on ____________
I canceled a reservation with a merchant within the guidelines set by that merchant and agreed to by me
at the time the reservation was initialed; however, my account was charged for the reservation.
Provide a cancellation number provided by merchant or reason you do not have a cancellation number:
Merchandise received on _______________________ was returned to merchant on __________________
Reason for dispute: ____________________________________________________________________
(
Provide signed proof of return or postal receipt)
Merchandise not received. Expected delivery date: __________ Date merchant contacted: _____________
Merchant response: ___________________________________________________________________
I have received a credit receipt from the merchant; however, the credit has not posted to my account.
(Provide copy of credit receipt (if applicable).
I certify that the services or merchandise charged to my account were paid by other means.
If no method of other payment can be determined, issue must be resolved between consumer and merchant.
(Provide a copy of the other method of payment: i.e. cash receipt, canceled check, credit card receipt or statement, etc.)
Incorrect amount. The amount on receipt is $ _____________ : however, $ ___________________ posted
to my account. (Must provide copy of receipt)
Other type of dispute (situation must be described in detail):
I am willing to take all reasonable action necessary to assist in the prosecution of the person(s) who committed this fraud.
I am authorizing the release of this information, including my ATM/Debit card information, to any local, state or federal
law enforcement agency for the purpose of assisting them in the investigation and prosecution of the person(s) who
committed this fraud.
Cardholder Signature: __________________________________________
____________ Date: _____________
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ATMDebit Card Transaction Dispute Form

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Completed 10 April 2022

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